HomeMy WebLinkAboutMortgage_Lizcano LLC 4: ;.-ate STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
�' State Forth 43709(R13110-15)
" Presorted by Department of Local Government FinanceF tidaINSTRUCTIONS:
To be filed in persona by mail. fi (y�h_
Filing Dates 1) Real Property Must be completed and dated in the calendar year for which the deduction is sought JAN L U I y
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is County Auditor
located on or before January 5 of the immediately succeeding calendar year. yI
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the coonty//[ C i�ty.Reeorder
where the properly is located during the twelve(12)months before March 31 of each year the deductionsyCIN
See reverse side for additional instructions and qualifications. GIt1JJ COUNTY AUDITOR
Applicant(owner or contract buyer restncoons on reverse side)
Li ze
Taxing D" "d Key number/legal description Record number Page number
. 7Z'—/I jZ—iO4—no,-968- 0.2- ? 0 I c( CAI - I -
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant a sole
assessment date,current year assessment date,anent year date of ap ,��22, legal or aged a owner?
250 COO Ft 20 bad c ❑ No
If no,what is his I her exact sham of interest? If owned with other than spouse,indicate with whom
if name on feted"s different than that of applicant,"uWicate below Is the in question:Annually Assessed
the
❑ Hone sed
Mobile Houle(IC 61.1-7)
Name of mortgagee or contract seller
two l r4 /2
Add of mortgagee or contract seller(number and street city,state.and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street city,state,and ZIP code)
Does applicant
cou licant own property in any If yes,what county? What Tat 'yl'' Has this deduction been requested If yes,state amount of deduction
in Indiana? ❑Yes 0 No current year?for ❑Yes 0 No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebtedness that is recorded in the county
recorders office(including any home equity line of credit that is recorded in the county recorders office)that is the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount of
20 20 20 20 20 ' 20' 20
Si to of County Auditor County Date(month,day,yea)
air �.S)�� , ,� �i�b.5v�2 r— 1 1— 1 9
I/We certify under the penalty of perjury that the ve and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
/ Signature(owls full name) „� Date(month,day,year)
XFWIresident taaddress of applicant(number` sheet city,state,and LP e)
X , 7,30 LI groat :;z: b-Irrz j f rp.1 IN) '-4767 0
Person authorized by duly executed Power of or by IC 6-1.1-12-0.7 I Date(month,day,year)
Address of authorized person (number and street city,state,and LP code)
The penalties for perjury can include imprisonment up to Iwo and a half years and a fine not to exceed$10,000.